Prostate Cancer and Sexual Function
Prostate Cancer and Sexual Function
January 14, 2009

John P. Mulhall, MD

Prostate Cancer
John P. Mulhall, MD, director of the Male Sexual and Reproductive Medicine Program at Memorial Sloan-Kettering Cancer Center in New York City, has written a new book titled Saving Your Sex Life: A Guide for Men with Prostate Cancer (Hilton Publishing Company, Chicago, 2008). In it, Dr. Mulhall discusses male sexual anatomy and sexual function; how prostate enlargement can cause sexual dysfunction; the effects of radical prostatectomy, radiation, and hormone therapy on sexual function; and strategies for recovering some or all of the patient's pre-surgery sexual function. It is the first book written exclusively for men with prostate cancer about sexual function.

The interview was conducted by Rosemary Frei, MSc, a Toronto-based medical journalist.

Who is your main audience?

Patients as well as urologists. There are plenty of physicians out there who are going to get prostate cancer. Everybody knows someone who's got prostate cancer.

What was your primary objective?

I realize doctors are uncomfortable with sexual issues, so I'm trying to empower patients to feel comfortable asking their physicians about this. Prostate cancer is a slow-growing cancer. So it's not as if men are diagnosed this week and need surgery the next. Men are not going to get the best treatment if they don't know what questions to ask, and they have time to do research and figure out what those questions should be. So there's a chapter about deciding on which treatment to have. I try to tie the decision in with sexual function—one of the topics for questions you should ask your doctor. For example, just because a doctor is a urologist doesn't mean he's an expert on radical prostatectomy—maybe he only does one a year. And we know that surgeon [procedure] volume is a predictor of success. So men need to ask how many he does.

Why was your book necessary? Do most urologists fail to discuss with prostate cancer patients the effects of treatment on their sex lives?

For physicians who manage prostate cancer patients, their first focus is oncologic—prostate-specific antigen measurements, etc. Their next concern is [restoring] continence. Sexual function isn't near the top of the list. And they often don't have the comfort level to talk to patients about it either. There's a famous slide I often use during talks—it shows a patient on a bed beside the doctor and both have “thought bubbles” that say, “I hope he brings up the topic of erection problems.” So it's usually on people's minds but rarely discussed. In addition, we only get one or two hours of sex medicine information in medical school. There's more time spent on tropical medicine.

How should urologists counsel prostate cancer patients?

The most important thing is to convey realistic expectations. I tell all the patients who come to see me the same thing: Don't base your decision [on which treatment to opt for] on sexual function. After three years, the outcomes from all the procedures are the same. Patients need to make an informed decision. If they don't know what questions to ask and the physician doesn't bring up sexual function, they're going to make an ill-informed decision. Every day I have a man sit in front of me with tremendous regret—with tears in his eyes—who tells me, “If I had known it was going to be like this, I would have never opted for that treatment.” Such patients weren't given realistic expectations.

It takes 18-24 months for most men to reach maximal recovery of sexual function after radical prostatectomy. The problem is that if patients are told they will recover [sexual function] in six months and erections haven't come back after nine months, they get depressed and stop doing anything [sexual]. Another consequence of unrealistic expectations is demonstrated in a European paper that was published earlier this year and looked at satisfaction with open vs. robotic-assisted prostatectomy. Satisfaction was lower with the robot because patients undergoing robotic prostatectomy are given unrealistic expectations, and their urinary and sexual outcomes are no better than with the non-robotic laparoscopic or open approach.

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